Children in rural areas face particular risks to their health
and well-being. Children who live outside of metropolitan areas are more
likely to live in poor families,1 have higher
mortality rates,2 and are more likely to use
tobacco3 than their counterparts in urban
areas. Rural families must travel greater distances to use health services;
452 non-metropolitan and frontier counties are designated as Health Professional
Shortage Areas for primary care, and 1,409 entire counties are considered
Medically Underserved Areas by the Federal government.4

The National Survey of Children’s Health (NSCH) presents
a unique resource with which to analyze the health status, health care
use, and risk factors experienced by children in rural areas in the context
of their families and communities. The NSCH was designed to measure the
health and well-being of children from birth to age 17 in the United States
while taking into account the environment in which they grow and develop.
Conducted for the first time in 2003, the survey collected information
from parents about their children’s health, including oral, physical
and mental health, health care utilization and insurance status, and social
well-being. Aspects of the child’s environment that were assessed
in the survey include family structure, poverty level, parental health
and habits, and community surroundings. The survey was supported and developed
by the U.S. Department of Health and Human Services, Health Resources
and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB)
and was conducted by the Centers for Disease Control and Prevention, National
Center for Health Statistics (NCHS).

Children were classified according to their residence in
an “urban focused” area, a large rural area, or a small or
isolated rural area, based on the size of the city or town and the commuting
pattern in the area. Urban-focused areas include metropolitan areas and
surrounding towns from which commuters flow to an urban area; large rural
areas include large towns (“micropolitan” areas) with populations
of 10,000 to 49,999 persons and their surrounding areas; and small or
isolated rural areas include small towns with populations of 2,500 to
9,999 persons and their surrounding areas. The map on page 6 shows how
these three types of areas are distributed across the United States. Of
the 72.7 million children in the U.S., 58.2 million live in urban-focused
areas, 7.2 million live in large rural areas, and 7.3 million live in
small rural or isolated areas.

Children in rural areas are more likely to be poor than
those in urban-focused areas: of children in small or isolated areas,
22.9 percent have family incomes below the Federal poverty level, as do
19.8 percent of those in large rural areas; this compares to 17.0 percent
of children in urbanfocused areas. Rural children are also more likely
to be non-Hispanic White. Among children in urban areas, 57.2 percent
are White, compared to 73.3 percent of children in large rural areas and
76.2 percent of children in small rural towns.

The NSCH found that children’s health status does
not vary substantially by location: approximately 84 percent of children
are reported by their parents to be in excellent or very good health,
regardless of their urban or rural status. However, rural children do
face specific health risks. Children in both large and small rural areas
are significantly less likely to be breastfed for at least 6 months, as
the American Academy of Pediatrics recommends: 40.5 percent of children
in urban-focused areas are breastfed for 6 months or more, compared to
31.7 percent of children in large rural areas and 31.4 percent of children
in small rural communities. In addition, rural children are more likely
to live in households where someone smokes. More than one-third of children
in rural areas (37.0 percent of children in large rural areas and 38.1
percent of children in small rural or isolated areas) live in households
with a smoker, compared to 27.5 percent of urban children.

Rural children may experience other risks to their well-being
as well. School-aged children in large and small rural areas are more
likely than urban children to have repeated a grade: 13.1 percent of children
aged 6-17 in large rural areas and 13.3 percent of children in small or
isolated rural areas have repeated a grade, compared to 10.8 percent of
children in urban-focused areas. Rural children, especially those in small
or isolated areas, are also more likely to stay home alone. Among 6- to
11-year-olds in small or isolated rural communities, 18.7 percent are
reported to have spent any time caring for themselves, without the supervision
of an adult or older child in the past week, compared to 16.1 percent
of children in large rural areas and 15.6 percent of children in urban-focused
areas.

In some cases, the effect of living in rural areas is particularly
pronounced for specific subpopulations. For example, low-income children
in rural areas are at higher risk of missing 11 or more days of school
due to illness and to have moderate or severe social-emotional difficulties
than children of the same income level in urban-focused areas or higher-income
children in rural areas. Some risk factors are especially prevalent among
specific racial/ethnic groups: compared to their urban counterparts, American
Indian/Alaska Native children in small rural areas are twice as likely
to be overweight, non-Hispanic White children in rural areas are more
likely to experience gaps in health insurance, and rural non-Hispanic
Black children are less likely to be breastfed for at least 6 months.

Living in rural areas also has health benefits for children.
A higher percentage of children in rural communities are reported by their
parents to be safe in their neighborhoods (90.2 percent of children in
small or isolated and 86.9 percent of children in large rural areas are
usually or always safe in their neighborhoods, compared to 82.6 percent
of children in urban-focused areas). Rural children are also more likely
to exercise regularly: 75.3 percent of children in small rural and 73.9
percent in large rural areas are reported to exercise regularly, compared
to 70.4 percent of children in urban areas.

This book presents information about the health and health
care of children by location and by major demographic characteristics
such as age, sex, race and ethnicity, and family income. Unless otherwise
noted, all graphs provide information on children from birth to age 17.
Children were classified by race and ethnicity in six categories: non-Hispanic
White, non-Hispanic Black, Hispanic, non- Hispanic American Indian/Alaska
Native (alone or in combination with other races), other single races,
and other combined races.

The Technical Appendix of this chartbook presents important
information about the survey sample and methodology. For more detailed
analyses of the survey results, the Data
Resource Center on Child and Adolescent Health (DRC) Web site,
which is sponsored by the Health Resources and Services Administration’s
Maternal and Child Health Bureau. It provides online access to the survey
data. The interactive data query feature allows users to create their
own customized tables and to compare survey results at the National and
State level, and by relevant subgroups such as age, race and ethnicity,
and family income.

This chartbook is based
on data from the National Survey of Children's Health. Suggested
citation: U.S. Department of Health and Human Services, Health Resources
and Services Administration, Maternal and Child Health Bureau. The National
Survey of Children's Health 2003. Rockville, Maryland: U.S. Department of
Health and Human Services, 2005.